NORTH CAROLINA ASSOCIATION OFMEDICAL STAFF SERVICES
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DATE:October 18, 2016
TO:All Current and Prospective Members of theNC Association of Medical Staff Services (NCAMSS)
FROM:Donna Phillips, CPMSM
President
SUBJECT: NCAMSS 2017 Membership/Renewal
The objectives of the Association shall be to provide the opportunity for continuing education and to promote the improvement of professional knowledge and skill by uniting persons who are engaged in credentialing activities through this State Organization under the auspices of the National Organization.
Membership Period: January 1, 2017 - December 31, 2017
(A prospective member who joins the Association and pays dues during the last quarter of the fiscal year shall satisfy dues requirement for the current year and the following year).
Please complete the NCAMSS Membership Applicationand return by December 31, 2016:
June Thomas
NCAMSS Treasurer
Vidant Duplin Hospital
PO Box 278, Kenansville, NC 28349
Phone: (910)296-2938 Fax: (910)296-2808
Please make checks payable to “North Carolina Association Medical Staff Services” Please note you may also pay membership fees at the NCAMSS Home Page using PayPal.
TYPE OF MEMBERSHIP:______Renewal______NewAmount Due: $ $100.00
CATEGORY OF MEMBERSHIP DESIRED: (Please () check one)
_____ Active(Persons involved in medical staff/credentialing activities. Eligible to vote and hold office)
_____ Associate (persons interested in the overall aims & objectives of NCAMSS. Not eligible to vote or hold office. Not eligible for scholarship.)
ORGANIZATION: ______
MAILING ADDRESS: ______
______
TELEPHONE #: ______FAX#: ______
NAME: ______Certifications: (CPMSM, CPCS, etc.) ______
Name you wish to go by if different from above: ______
TITLE: ______
EMAIL ADDRESS: ______
Please note if youdo not wish to have your email published on our website for surveys, etc. please mark this box:
MAKE ADDITIONAL COPIES AS NEEDED
Membership Bonus: Individual hospitals/health systemswith three or more members in the Association may apply for the group membership rate as follows: $100.00 for the first person and $50.00 for each additional person per year. You must indicate all names on the application and payment must be submitted at the same time.
TYPE OF MEMBERSHIP:______Renewal______NewAdditional Amount Due: $ $50.00
CATEGORY OF MEMBERSHIP DESIRED: (Please () check one)
_____ Active(Persons involved in medical staff/credentialing activities. Eligible to vote and hold office.)
_____ Associate (persons interested in the overall aims & objectives of NCAMSS. Not eligible to vote or hold office.Not eligible for scholarship.)
ORGANIZATION: ______
MAILING ADDRESS: ______
______
TELEPHONE #: ______FAX#: ______
NAME: ______Certifications: (CPMSM, CPCS, etc.) ______
Name you wish to go by if different from above: ______
TITLE: ______
EMAIL ADDRESS: ______
Please note if you do not wish to have your email published on our website for surveys, etc. please mark this box:
TYPE OF MEMBERSHIP:______Renewal______NewAdditional Amount Due: $ $50.00
CATEGORY OF MEMBERSHIP DESIRED: (Please () check one)
_____ Active(Persons involved in medical staff/credentialing activities. Eligible to vote and hold office)
_____ Associate (persons interested in the overall aims & objectives of NCAMSS. Not eligible to vote or hold office. Not eligible for scholarship.)
ORGANIZATION: ______
MAILING ADDRESS: ______
______
TELEPHONE #: ______FAX#: ______
NAME: ______Certifications: (CPMSM, CPCS, etc.) ______
Name you wish to go by if different from above: ______
TITLE: ______
EMAIL ADDRESS: ______
Please note if you do not wish to have your email published on our website for surveys, etc. please mark this box:
NCAMSS Membership dues are used to pay for speaker fees, travel expenses, general meeting expenses, audiovisual equipment rental for the annual meeting, audiovisual equipment, copy fees, mailing labels, postage, annual meeting give-a-ways, annual and quarterly meeting door prizes, food expenses, Internet webpage maintenance fees, and all other association expenses deemed appropriate and approved by the officers of the board of NCAMSS. Meeting registration fees are also used to supplement the expenses of the NCAMSS.